Blood Pressure Management in HFpEF on Metoprolol
In this 65-year-old patient with HFpEF already on metoprolol ER 100 mg, blood pressure should be controlled to a target of <130/80 mmHg using ACE inhibitors or ARBs as first-line additions, with diuretics for symptomatic fluid management, and SGLT2 inhibitors (dapagliflozin or empagliflozin) should be initiated immediately as disease-modifying therapy regardless of diabetes status. 1, 2, 3
Primary Blood Pressure Target and Strategy
Target BP is <130/80 mmHg in this patient with HFpEF and cardiovascular risk factors, though <140/90 mmHg is acceptable given age ≥65 years. 1, 2
The patient is already on metoprolol ER 100 mg, which is reasonable for BP control in HFpEF, though beta-blockers have limited mortality benefit specifically in HFpEF compared to HFrEF. 1, 4
First-Line Antihypertensive Additions
Add an ACE inhibitor or ARB as the next agent for BP control in HFpEF:
ACE inhibitors and ARBs are specifically recommended as reasonable first-line agents for BP control in HFpEF patients with hypertension. 1
These agents provide BP reduction without the robust mortality benefits seen in HFrEF, but they are guideline-endorsed for hypertension management in this population. 1
Start with standard doses (e.g., lisinopril 10 mg daily or losartan 50 mg daily) and titrate to BP target. 1
Essential Disease-Modifying Therapy
Initiate an SGLT2 inhibitor immediately (dapagliflozin 10 mg daily or empagliflozin 10 mg daily):
SGLT2 inhibitors reduce HF hospitalizations by 21-29% and are now first-line therapy for HFpEF regardless of diabetes status. 2, 3
The American College of Cardiology recommends not delaying SGLT2 inhibitor initiation as these have proven mortality benefits. 3
These agents also provide modest BP reduction (3-5 mmHg systolic), contributing to overall BP control. 2
Diuretic Management
Continue or optimize loop diuretics at the lowest effective dose for symptomatic relief of fluid retention. 1, 2
Diuretics improve symptoms but have not been shown to improve prognosis in HFpEF. 2
Monitor for volume depletion, electrolyte abnormalities, and worsening renal function with aggressive diuresis. 1, 3
Additional Considerations
Mineralocorticoid receptor antagonist (spironolactone) may be considered:
Spironolactone 12.5-25 mg daily can be added in appropriately selected patients (potassium <5.0 mEq/L, creatinine <2.5 mg/dL, eGFR >30 mL/min) to potentially decrease hospitalizations. 1, 2
The TOPCAT trial showed modest reduction in HF hospitalization (HR 0.83) though the composite endpoint did not reach statistical significance. 1
Monitor potassium and creatinine closely due to hyperkalemia risk, especially when combined with ACE inhibitors/ARBs. 1, 3
Metoprolol Optimization
The current dose of metoprolol ER 100 mg is reasonable but suboptimal if BP remains elevated. 1
Metoprolol succinate can be titrated up to 200 mg daily if needed for BP control and heart rate management, though evidence for mortality benefit in HFpEF specifically is limited. 1, 4, 5
A pilot study showed metoprolol may provide some symptomatic benefit in HFpEF, but larger trials are needed. 4
Critical Monitoring
Assess BP, heart rate, volume status, and symptoms at each visit. 3
Monitor serum electrolytes (especially potassium), BUN, and creatinine when initiating or titrating RAAS inhibitors and MRAs. 1, 3
Daily weights and signs of congestion should be monitored by the patient at home. 3
Common Pitfalls to Avoid
Do not withhold SGLT2 inhibitors thinking they are only for diabetics—they are disease-modifying therapy for all HFpEF patients. 2, 3
Avoid excessive diuresis leading to hypotension and prerenal azotemia, which can limit use of other guideline-directed therapies. 1, 3
Do not assume beta-blockers alone are sufficient for HFpEF management—unlike HFrEF, the evidence for beta-blocker mortality benefit in HFpEF is weak. 1, 6
Monitor for hyperkalemia when combining ACE inhibitors/ARBs with MRAs, particularly in patients with baseline CKD. 1